Musculoskeletal: Joint hypermobility

Joint hypermobility is a condition in which individual joints move beyond the normal range.

People who have joint hypermobility will often also have a natural aptitude for gymnastics (Photo: GUSTOIMAGES/SCIENCE PHOTO LIBRARY)
People who have joint hypermobility will often also have a natural aptitude for gymnastics (Photo: GUSTOIMAGES/SCIENCE PHOTO LIBRARY)

It is common, affecting 10-20% of young adults, and is thought to be caused by an abnormal ratio of collagen fibre types.

It is inherited as an autosomal dominant trait and can be acquired through years of training and stretching, seen particularly in ballet dancers and gymnasts.

People with joint hypermobility often have a natural aptitude for dancing, gymnastics and playing musical instruments. However, due to the excessive play on the range of movement, proprioceptive difficulties can occur. Evidence shows these individuals are less proficient in ball-catching skills.

Hypermobility is more prevalent in females and those of African or Asian descent. It decreases with age and prevalence is thought to be 5% in adults.

Symptoms frequently present in childhood and suspicions should be raised with non-specific symptoms such as joint pains, stiffness, clicking or 'popping', and 'growing pains'. Areas commonly involved are the ankles, knees and back.

Examination

A quick examination technique is to ask the patient to place their palm on the desk and keep their fingers flat, while raising the dorsum of the hand. Children usually manage just above 45 degs, although hypermobile children can hyperextend to 90 degs or more. There is also a five-point questionnaire (see box, above right).

At the severe end of the spectrum, joint hypermobility syndrome (JHS) can occur, leading to arthralgia, soft tissue injury and joint instability.

Associated complications of JHS include autonomic dysfunction causing irritable bowel syndrome, diminished effectiveness of local anaesthetics, ligament/joint laxity leading to back and pelvic pain in pregnancy and childbirth, increased risk of rectal and/or urogenital prolapse, carpal tunnel syndrome, fibromyalgia and ME type syndrome, increased frequency of anxiety/depression, and low bone density.

JHS is diagnosed using the nine-point Beighton scale (see table). A general examination usually elicits certain signs adopted by patients to achieve joint stability by tightening ligaments, including frequent slouching and hyperextension of fingers, holding knees and hips hyperextended and the lumbar spine in a 'sway' position when standing, and flat feet; in addition, joints often have an 'empty' or 'boggy' end feel.

The Beighton scale for diagnosing JHS
Description Test Points
Passive dorsiflexion of fifth metacarpophalangeal joint >90° Left
Right

1
1

Opposition of thumb to the volar aspect of the ipsilateral forearm Left
Right
1
1
Hyperextension of elbow >10° Left
Right
1
1
Hyperextension of knee >10° Left
Right
1
1
Placing of palms flat on floor without bending knees   1
JHS requires a Beighton score >4 and arthralgia in four or more joints for more than three months.

Management

In most cases of simple joint hypermobility, patients do not suffer any long-term problems. However, some individuals with simple joint hypermobility may experience childhood aches and pains, recurrent joint strains and 'growing pains'.

Advice can be given by a general physiotherapist to promote joint protection. Education would aim to instil correct posture maintenance, body awareness, safe physical activity and elimination of certain habits, such as kneeling on the floor with the feet tucked under.

In established JHS, the advice is given with an emphasis on fitness, balance and co-ordination through regular safe physical activity, as well as advice to promote joint stability. Hydrotherapy is useful, as are Pilates and tai chi, some forms of yoga and dance. Podiatry can provide the patient with mechanical foot assessment and orthotics.

This specialised advice is best given by a rheumatology-based physiotherapist. Joint hypermobility is at best poorly understood and at worst remains undiagnosed.

Pain is one of the most common reasons for consulting a healthcare professional and in many cases the causes are non-specific. Having a high suspicion of joint hypermobility, especially in younger patients, can have a significant effect on the outcome of many musculoskeletal complaints.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

  • Dr Ross is a GP in Glasgow

Identify the condition

'Yes' to two or more questions suggests hypermobility

Can you place your hands flat on the floor without bending your knees?

Can you bend your thumb to touch your forearm?

Can you contort your body into unusual shapes? Can you do the splits?

Have you ever had problems with shoulder or kneecap dislocation?

Do you consider yourself double jointed?

Source: Hakim AJ, Graham R.

Int J Clin Pract 2003; 57: 163-6

Resources

Simmonds JV, Keer RJ. Hypermobility and the hypermobility syndrome, parts 1 and 2. Manual Ther 2007; 12(4): 298-309 and Manual Ther 2008; 13(2): e1-11.

Ross J, Grahame R. Joint hypermobility syndrome. BMJ 2011; 342: c7167.

Keer RJ. How hypermobility contributes to pain. Managing Pain in Practice 2011; 2(1): 7-8.

Simpson MR. Benign joint hypermobility syndrome: evaluation, diagnosis and management. J Am Osteopath Assoc 2006; 106(9): 531-6.

Hypermobility Syndrome Association. www.hypermobility.org

Arthritis Research UK. www.arthritis researchuk.org/arthritis-information /conditions/joint-hypermobility

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